Self-testing and self-management of oral anticoagulation therapy in children

Abstract

SummaryChildren and adolescents on oral anticoagulation therapy (OAT) present special challenges in terms of rapid fluctuations in International Normalised Ratio (INR) values, interruption in daily life due to frequent hospital/doctor visits, and difficulties and pain in the performance of venepuncture. Optimised management of OAT improves the quality of treatment, potentially accomplished by new methods such as patient self-testing (PST) and patient self-management (PSM). A review was performed, identifying 11 trials with children and adolescents. All studies had different methodological problems, predominantly by being non-randomised trials. A total of 284 patients were included with a mean follow-up of 22 months, finding a time within therapeutic INR target range between 63% and 84%. The coagulometers used for esti- mating the INR values were found to have sufficient precision and accuracy for clinical use, but external quality control is probably advisable. It can be concluded that PST and PSM are at least as good treatment options as conventional management in highly selected children. Larger studies, preferably randomised, controlled trials using clinical endpoints, are obviously needed in order to elucidate whether these new regimens of treatment are superior to conventional management of oral anticoagulation therapy.

Using an electronic medical record patient portal for warfarin self-management: Empowering children and parents

“…The relationship with the clinical team was central to building knowledge and confidence; this highlights the significance of having a dedicated anticoagulation service to support children on warfarin and their families and how specialized education and clinical expertise contribute to empowering families and improving outcomes [ 24 ]. This has been echoed in other studies of pediatric PSM and PST programs for children [ 5 , 8 , 10 , 20 , 21 , 25 ].…”

Self-managed oral anticoagulant therapy: a call for implementation

“…It has been demonstrated to be possible to perform PSM safely in both adults and a pediatric setting, the latter, of course, with the support of the parents [10]. In adults, it is estimated that approximately 50% of all patients prescribed OAT are able to perform PSM.…”

Guiding warfarin self-management in children: development of a warfarin nomogram

“…Specifically, for INRs out of target range, there were instances where there was insufficient detail to determine if there was a recognized factor contributing to the clinician’s warfarin dosing or INR retesting decision which would align with advice from the nomogram. For example, clinicians recording a child was “unwell with cold” would be consistent with a corresponding factor in the nomogram such as “respiratory type of illness for more than 48 hours, fever, cough, lethargy, and runny nose with reduced appetite.” Further testing of this pediatric warfarin nomogram across a larger population is needed, as the highly selected inclusion criteria may limit capacity to extrapolate the results to a broader population of children at the tertiary hospital receiving long-term warfarin therapy, as suggested by Christensen [ 20 ]. To also explore how clinical factors affect the application of the nomogram, measurement of inter-user agreement is recommended in future studies.…”

“…Pediatric warfarin PSM involves families testing the child’s INR with a point-of-care device and then, if required, altering the dose of warfarin administered to maintain the child’s INR within their target therapeutic range (TTR) [ [18] , [19] , [20] ]. Several small pediatric studies have demonstrated that empowering families to undertake PSM is safe, increases their knowledge of the child’s condition, and improves their commitment to the child’s health care, warfarin therapy adherence, and health-related quality of life [ [18] , [19] , [20] ]. Two previous PSM studies reported the dosing strategy used to guide families undertaking warfarin PSM, but no studies have validated the dosing strategy or tool utilized by families to make warfarin dosing and INR retesting decisions [ 14 , 18 ].…”